Big Pharma tap­ping into med­i­cal records

Hamil­ton MDs fear soft­ware helps drug­mak­ers profit

It’s like a coupon: If a pa­tient’s in­sur­ance doesn’t cover the full cost of a pricier brand name drug, the drug’s man­u­fac­turer will cover part or all of the cost dif­fer­ence from its generic equiv­a­lent.

Elec­tronic pa­tient records in doc­tors’ of­fices across the coun­try are be­ing used by brand name drug com­pa­nies look­ing to muscle mar­ket share away from generic com­peti­tors, a Toronto Star in­ves­ti­ga­tion has found.

Con­cerned physi­cians say a clin­i­cal tool they use to write pre­scrip­tions and care for pa­tients is be­ing co-opted, and they fear health records are be­ing tapped so drug com­pa­nies can in­crease prof­its.

In the bat­tle for phar­ma­ceu­ti­cal dom­i­nance, this new tac­tic, de­ployed in soft­ware used by doc­tors, has al­lowed brand-name com­pa­nies to cap­i­tal­ize on the mo­ment a pre­scrip­tion is writ­ten. Here’s how it works: The pa­tient records are found in EMRs, or elec­tronic med­i­cal record soft­ware, owned by Telus Health, a sub­sidiary of the tele­com gi­ant. The soft­ware is used by thou­sands of Cana­dian doc­tors to take notes dur­ing pa­tient vis­its and to cre­ate a pre­scrip­tion to be filled by the pa­tient’s phar­macy.

To drive busi­ness their way, brand-name drug com­pa­nies have paid Telus to dig­i­tally in­sert vouch­ers so that the pre­scrip­tion is filled with their prod­uct in­stead of the lower-cost generic com­peti­tor that phar­ma­cists nor­mally reach for.

The vouch­ers are known in the in­dus­try as “pa­tient-as­sis­tance pro­grams.” It works like a coupon: If a pa­tient’s in­sur­ance does not cover the full cost of the pricier brand name drug, the drug’s manuf ac­turer will cover part or all of the cost dif­fer­ence from its generic equiv­a­lent.

The voucher fea­ture is of­fered in a num­ber of other elec­tronic med­i­cal record sys­tems, Telus said.

Doc­tors had to agree to the new fea­ture in the Telus soft­ware be­fore it was en­abled on their sys­tems, and physi­cians can opt out at any time.

But some physi­cians may not re­al­ize the im­pli­ca­tions of the vouch­ers when they click to ac­cept the soft­ware’s up­dated fea­tures, said Dr. Antony Gagnon, man­ager of the phar­macy pro­gram with the Hamil­ton Fam­ily Health Team.

“The brand name com­pa­nies are ba­si­cally us­ing physi­cians to re­di­rect their pre­scrip­tions of generic drugs to the com­pa­nies’ brand drugs,” Gagnon said.

In an in­ter­nal doc­u­ment ob­tained by the Toronto Star, the head of On­tario’s doc­tor reg­u­la­tor, speak­ing gen­er­ally, said vouch­ers be­ing in­cluded on a pre­scrip­tion is “not ap­pro­pri­ate” as they may lead pa­tients to think their physi­cians favour brand drugs over gener­ics.

Gener­ics con­tain the same med­i­cal in­gre­di­ents and can cost as lit­tle as one-fifth of the brand price. A for­mer as­sis­tant deputy health min­is­ter, He­len Steven­son, said the vouch­ers can pile un­nec­es­sary costs on to pri­vate drug plans. These costs could ul­ti­mately be passed to the pa­tient through higher pre­mi­ums.

In an in­ter­view, Telus Health pres­i­dent Paul Lepage de­fended the pro­gram, say­ing that elec­tronic vouch­ers stream­line pay­ment as­sis­tance pro­grams al­ready “used by mil­lions of Cana­di­ans who re­ally use them to re­duce the cost of their med­i­ca­tion.”

In the past, drug com­pany reps gave pa­per vouch­ers to physi­cians who in turn could hand them out to the pa­tient.

With the up­dated soft­ware, the voucher can be printed right on the pa­tient’s pre­scrip­tion.

“Our physician cus­tomers who use these pro­grams have asked us if we can sim­plify the process,” said Lepage of Telus. “We’re fo­cused on of­fer­ing cost-ef­fec­tive so­lu­tions to physi­cians and pa­tients.”

The voucher func­tion has been “very pos­i­tively re­ceived by the ma­jor­ity of our physician users,” a Telus spokesper­son said.

Why do brand name com­pa­nies of­fer these vouch­ers?

In an ef­fort to keep costs down, many drug plans en­cour­age phar­ma­cists to sub­sti­tute a cheaper generic drug when fill­ing a pre­scrip­tion for a brand drug, un­less the pre­scrib­ing doc­tor specif­i­cally re- quests oth­er­wise. With­out the voucher, even if a doc­tor uses the brand name on a pre­scrip­tion, phar­ma­cists may sub­sti­tute the cheaper generic.

But when en­abled, the Telus soft­ware fea­ture de­tects when a doc­tor is pre­scrib­ing a drug by its brand name, such as choles­terol med­i­ca­tion Crestor. The voucher is printed on the pre­scrip­tion and the phar­ma­cist takes that as a spe­cific in­struc­tion to dis­pense the brand name. The voucher is not of­fered if the doc­tor en­ters the generic name (ro­su­vas­tatin, in Crestor’s case), Telus said.

The brand com­pa­nies say the pay­ment as­sis­tance vouch­ers are about giv­ing the pa­tient choice be­tween brand and generic drugs with­out hav­ing to spend more money.

But for Gagnon, the vouch­ers are ma­nip­u­lat­ing physi­cians’ pre­scrib­ing prac­tices, adding that many physi­cians use a drug’s brand name when writ­ing a pre­scrip­tion out of habit and aren’t nec­es­sar­ily in­struct­ing that a drug be dis­pensed over its generic.

The vouch­ers also re­in­force a false premise that gener­ics are in­fe­rior in qual­ity to the orig­i­nal brand name drugs, say doc­tors crit­i­cal of the pro­gram.

The first time Toronto physician Nav Per­saud logged on to Telus’ PS Suite af­ter its re­cent up­date, a text box popped up no­ti­fy­ing him of the new fea­ture that could “lead to greater choice and lower cost for your pa­tients.”

But Per­saud ques­tioned how much his pa­tients would get out of the vouch­ers.

“It wasn’t clear to me who was go­ing to ben­e­fit from it. Was it go­ing to fur­ther the mar­ket­ing of brand name prod­ucts, which I think are pre­scribed with­out any clear rea­son, given that they have the same ef­fects (as gener­ics), and they cost more?” said Per­saud, a f am­ily physician at St. Michael’s Hos­pi­tal. He dis­abled the fea­ture. A Telus spokesper­son said the voucher is of­fered only af­ter a physician chooses a spe­cific brand name drug to pre­scribe, “so there is no in­flu­ence on what drug the physician se­lects.”

“As a tech­nol­ogy provider, we are care­ful not to in­flu­ence or re­strict the clin­i­cal choices made by med­i­cal pro­fes­sion­als.”

Telus Health is a dom­i­nant player in Canada’s elec­tronic med­i­cal record in­dus­try. Its seven EMR sys­tems im­pact more than 25 mil­lion pa­tient-physician in­ter­ac­tions each year.

Two of those pro­grams — PS Suite and Nightin­gale — have the fea­ture of­fer­ing pay­ment as­sis­tance vouch­ers. Telus plans to ex­pand the fea­ture to all of its EMR pro­grams. Brand com­pa­nies pay on a “fixed-fee ba­sis” for their vouch­ers be­ing in­cluded, Telus of­fi­cials said, but they re­fused to dis­cuss the de­tails of their agree­ment with drug com­pa­nies, say­ing it was “sub­ject to com­mer­cial con­fi­den­tial­ity.”

About 7,000 doc­tors across Canada use PS Suite, and roughly two-thirds have cho­sen to use the voucher func­tion. The com­pany said doc­tors were in­volved in de­sign­ing the fea­ture.

In the med­i­cal prac­tices of the Hamil­ton Fam­ily Health Team, a net­work of 165 physi­cians, some doc­tors were un­aware of the voucher fea­ture — nor were they aware that in­for­ma­tion about those vouch­ers was be­ing shared with drug com­pa­nies.

Some of those doc­tors send the pre­scrip­tions di­rectly from their com­put­ers to the phar­macy fax ma­chine and never saw the voucher that was in­cluded on the print­out, said lead physician Dr. Mon­ica De Benedetti.

With­out the doc­tors be­ing fully aware, they could not tell their pa­tients about the pro­gram, De Benedetti said.

The health team en­cour­aged its mem­bers to turn off the voucher fea­ture. In 2016, De Benedetti, along with Gagnon and the Health Team’s ex­ec­u­tive di­rec­tor, wrote a com­plaint let­ter to Telus Health.

“There will cer­tainly be a num­ber of physi­cians who will be con­cerned that they are in­ad­ver­tently par­tic­i­pat­ing in con­tribut­ing data to phar­ma­ceu­ti­cal com­pa­nies,” the let­ter read.

Telus said all doc­tors had to en­able the new voucher fea­ture by click­ing “ac­cept” in a pop-up text box.

Drug man­u­fac­tur­ers pay­ing to have their vouch­ers in the EMR re­ceive “ag­gre­gated and anonymized, prov­ince-level sta­tis­tics” on the to­tal num­ber of vouch­ers printed off for their prod­ucts, the com­pany said.

JESSE MCLEAN, TORONTO STAR

Doc­tors Antony Gagnon, left, Michael Pray and Mon­ica De Benedetti of the Hamil­ton Fam­ily Health Team raised con­cerns about drug vouch­ers in­serted in elec­tronic med­i­cal records. They say a clin­i­cal tool they use to care for pa­tients is be­ing co-opted so brand name drug­mak­ers can sell more prod­ucts.